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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 8 of 8. This is the beginning of the thread.
Posted by Schlepo on December 24, 2018, at 10:02:23
I've seen these combos suggested for augmenting nortriptyline, and wondering if anyone ever actually tried them. There are some theoretical contraindication concerns with Remeron, but I've heard its possible to combine them since they don't act on the exact same areas. Any clarifications for either combo?
Posted by linkadge on December 25, 2018, at 21:01:14
In reply to Anyone ever augment a TCA with Zoloft or Remeron?, posted by Schlepo on December 24, 2018, at 10:02:23
I haven't used a TCA with Zoloft per se, but I have used combinations of TCAs and SSRIs (amitriptyline, nortriptyline and escitalopram). I have also used mirtazapine (Remeron) with SSRIs. I have also used (briefly) a TCA / mirtazapine combination (nortriptyline and mirtazapine).
There are no direct interactions between mirtazapine, TCAs or SSRIs. In theory, they can all increase serotonergic function and there are case reports of serotonin syndrome. However, its not on the same level as with MAOIs. I've never had an interaction with the mentioned meds, although I only used low doses.
Mirtazapine and nortriptyline were effective together, although both increase norepinephrine (through different mechanisms) and so blood pressure should be monitored. Mirtazapine can be a useful adjunct to an SSRI, if sleep and appetite are issues. Adding a TCA (especially the noradrenergic ones) to an SSRI can provide an additional (complimentary) mechanism and can help with sleep and / or energy levels.
Mirtazapine and TCAs share some common mechanisms (5-ht2a/c antagonism, and antihistamine effects). You may find some overlap in the effect of say, mirtazapine and a TCA like amitriptyline (i.e. both are sedating, and typically taken before bedtime).
Sertraline is mainly an SSRI (with some weaker effects on dopamine reuptake). Adding a TCA like nortriptyline would provide additional norepinephrine reuptake - i.e. having some effect on all three monoamines.
Linkadge
Posted by Schlepo on December 26, 2018, at 10:33:03
In reply to Re: Anyone ever augment a TCA with Zoloft or Remeron?, posted by linkadge on December 25, 2018, at 21:01:14
Thanks. Are there any kinds of established "best" combos of nortriptyline and another antidepressant, or are they all essentially YMMV?
Posted by linkadge on December 26, 2018, at 13:00:59
In reply to Re: Anyone ever augment a TCA with Zoloft or Remeron?, posted by Schlepo on December 26, 2018, at 10:33:03
Hey,
Nortriptyline and/or desipramine seem to be the most talked about (and perhaps studied) TCAs for augmentation purposes. I think the rationale is that, they are primarily noradrenergic and so the mechanism would complement an SSRI.
I have heard more about nortriptyline with sertraline (for some reason). However, I'm not sure if it is more effective than other combinations. Nortriptyline tends to be better tollerated than say amitriptyline (less sedation and fewer anticholinergic side effects).Linkadge
Posted by Schlepo on December 26, 2018, at 17:06:04
In reply to Re: Anyone ever augment a TCA with Zoloft or Remeron?, posted by linkadge on December 26, 2018, at 13:00:59
Do you remember the dosage when you were on the nortriptyline/Remeron combo? I would be complementing 125mg of nortriptyline (I don't think I'd be able to go less than 100mg of nortrip). And what do you know of the dosages for Zoloft augmentation?
Posted by linkadge on December 27, 2018, at 10:51:14
In reply to Re: Anyone ever augment a TCA with Zoloft or Remeron?, posted by Schlepo on December 26, 2018, at 17:06:04
Hi.
I just wrote a long response and it got erased (arggg).I was taking lower doses (20-30mg of nortriptyline) and added 7.5-15mg of mirtazapine as my sleep was not good.
There may not be a need to lower the nortriptyline. You could keep this at the current dose and then slowly add a 2nd med. For mirtazapine, I wouldn't take more than 7.5mg to start (perhaps even 3.75mg). For sertaline, I would start with 25mg.
Keep in mind, these two meds could have very different effectsmirtazapine
-----------
- good for sleep, anxiety, and low appetite
- lower risk of sexual dysfunction
- may improve cognition
- higher daytime sedation (especially to start)
- some don't find it as strong on core depression symptoms (although varies quite a bit from person to person)
- may cause weight gainsertaline
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- more activating than mirtazapine
- weight neutral
- good for anxiety / depression
- will cause less daytime sedation
- may cause more sexual dysfunctionIf it was a toss up between these two, I might go for sertaline first (unless insomnia, anxiety are predominant, then mirtazapine might be a better choice). TCAs and SSRIs are combined fairly regularly. There is no direct contraindication (as with
MAOIs). If you start the 2nd med slowly and increase slowly, you should be able to catch an interaction. Sertaline can increase the blood level of nortriptyline (usually only to a small extent), so ultimately, you may get away with less nortriptyline. I'm not sure if you are getting theraputic testing for nortriptyline levels. If so, you may want to check the nortripyline levels. Nortriptyline can have more side effects if the level gets too high. However, this may just mean you ultimately need less nortiprtline.https://www.ncbi.nlm.nih.gov/pubmed/9375595
Linkadge
Posted by Schlepo on December 27, 2018, at 19:18:32
In reply to Re: Anyone ever augment a TCA with Zoloft or Remeron?, posted by linkadge on December 27, 2018, at 10:51:14
Thanks again. I'm just as concerned about over-medicating, my system being very sensitive. Drowsiness is in a way just as bad to me as anxiety/depression; even when I was on just .25mg of clonazepam my activities were limited by drowsiness.
Posted by bleauberry on December 29, 2018, at 8:20:39
In reply to Anyone ever augment a TCA with Zoloft or Remeron?, posted by Schlepo on December 24, 2018, at 10:02:23
I've been on every combination you can think of involving these 3 meds.
I do not think you can predict the results in advance with these. You just have to try and see what happens.
Combining any of them does make sense because their respective mechanisms are very different. The anti-histamine effect would be extra strong with Nortriptyline and Remeron together but that is not necessarily a bad thing, and potentially therapeutic (in my thinking, many depressions have inflammation at their root and that means excess histamine response).
For me any of these alone were too emotionally numbing, and any combinations of them were even more numbing.
If you need some sort of arousal or pleasure component in your antidepressant therapy then you need to be looking at the stimulants not the reuptake inhibitors.
> I've seen these combos suggested for augmenting nortriptyline, and wondering if anyone ever actually tried them. There are some theoretical contraindication concerns with Remeron, but I've heard its possible to combine them since they don't act on the exact same areas. Any clarifications for either combo?
This is the end of the thread.
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